Pointers for the Effective Prescription of Chinese Patent Medicines
By Bob Flaws, LAc, FNAAOM (USA), FRCHM (UK)
In professional Chinese medicine as practiced in the People's Republic of China, the basic prescriptive methodology is known as bian zheng lun zhi. This translates as basing treatment on pattern discrimination.
Basing treatment on pattern discrimination is the single best (and most important) methodology for the safe and effective prescription of any Chinese medicinals, be they individually bulk-dispensed or ready-made. Basing treatment on pattern is what makes professional Chinese medicine holistic, safe and effective.
A Chinese medical pattern is the total of all signs and symptoms gathered by the Chinese four examinations (looking, smelling/hearing, questioning and palpating). The signs and symptoms that make up a person's Chinese pattern discrimination are usually greater in number than the signs and symptoms which define their disease diagnosis. The disease is a tree, but the pattern is the forest in which this tree exists. The disease is a figure, but the pattern is the ground, and it is the pattern that professional Chinese medicine primarily seeks to treat.
In professional Chinese medicine, we first rebalance or regulate the patient's pattern of disharmony. Only secondarily do we make sure our choice of treatment also empirically addresses the patient's disease or major complaints. Thus it is said in Chinese medicine:
Different diseases, same treatment Same diseases, different treatments
This means that two patients may have the same disease diagnosis, yet if their Chinese pattern discrimination is different, they will receive quite different treatments. Conversely, two patients may be diagnosed as suffering from two quite different diseases, yet they will receive essentially the same treatment if their Chinese pattern discrimination is the same. When performing professional Chinese medicine, we first choose and aim our treatment at the patient's pattern. Only secondarily do we make sure that treatment is clinically known through previous experience to address the patient's disease diagnosis.
As stated above, it is treatment given on the basis of pattern discrimination that makes professional Chinese medicine holistic, safe and effective. This is because it treats the entire person. When a medicine provokes unwanted side-effects in some patients, it is because that medication was not right for that person. It may address a specific symptom, but it did not take into account the ground in which that symptom exists. Medicines which cause side-effects and unwanted, allergic or toxic reactions are all erroneously prescribed. They are neither good nor bad within themselves. They simply have been prescribed to the wrong person, the wrong pattern of that disease.
Therefore, if a practitioner of Chinese medicine begins by asking what Chinese ready-made medicine treats this or that disease, they are asking the wrong question and starting from the wrong place. On the other hand, we will never go wrong if we first conduct a Chinese pattern discrimination and pick a remedy primarily on that basis.
Professional Standards of Care
In professional Chinese medicine, there are definite standards of care regarding what treatment principles go with what patterns. Although there is some room for synonyms, there is remarkable consistency within the modern Chinese medical literature concerning what treatment principles go with what patterns. For instance, we use the principles of drying dampness when that dampness encumbers the middle burner, but we use the principle of disinhibiting dampness when evil dampness is located primarily in the lower burner.
A good sense of the appropriate treatment principles for different patterns using Wiseman's terminology can be seen in A Compendium of TCM Patterns and Treatments. Personally, I recommend sticking with the treatment principles that correlate to the chapters or categories of Chinese materia medica and formula and strategy texts. It will help keep things simple.
Prioritizing Patterns (and Therefore, Treatment)
If we say a patient is exhibiting a pattern of liver depression with spleen vacuity, by putting the words liver depression first, we imply that liver depression is the most important factor, and spleen vacuity is secondary. If our patient primarily exhibits spleen vacuity with a touch of liver depression, it is important to say that their pattern discrimination is spleen vacuity with simultaneous liver depression.
Whatever the order of our pattern discrimination, it should be the same order of our statement of treatment principles. If we stick with this protocol or methodology, our guiding formula or prescription will typically be found in the category that corresponds to the first treatment principle.
If we say that the pattern is liver depression with spleen vacuity, it is categorically wrong to pick a formula from the qi-supplementing chapter. Similarly, if we say there is spleen vacuity complicated by damp heat, it is categorically wrong to pick a formula from the heat-clearing, dampness-eliminating subcategory of the heat-clearing category. Rather, we should first look in the qi-supplementing category, or at least in the harmonizing category.
Warranted and Unwarranted Treatment
Additionally, it is very important to not add any treatment principles not warranted by the pattern discrimination. Everything said in the pattern discrimination should be reflected in the treatment principles. Nothing should suddenly appear in the treatment principles not logically derived from the stated pattern. If one has not said there is kidney yang vacuity in the pattern discrimination, one cannot suddenly say to supplement the kidneys and invigorate yang.
The word "warrant" is extremely important. In legal terms, "warrant" gives officers of the law the legal right to do something that is otherwise illegal. To hold or take someone somewhere against their will is called kidnapping, yet police do this all the time. To do this, they must first get an arrest warrant from a judge. In order to get a warrant, they must present the judge with evidence that the suspect is the person who has committed the crime.
In Chinese medical terms, signs and symptoms are our proof of a patient's pattern. If we say they have a certain pattern, they have to exhibit certain signs and symptoms. If they don't exhibit such signs and symptoms, they categorically do not exhibit that pattern. Our treatment principles are our warrant to use certain medicinals, and we can only include those medicinals for which we have a warrant. Therefore, it is very important in the Chinese medical process of moving from signs and symptoms, to pattern discrimination, to a treatment plan, that one does not add any treatment principles without A) substantiating evidence and B) deriving those principles from some element of the stated pattern discrimination.
Recapitulation of Basic Chinese Medical Methodology
When presented with a new patient, a practitioner first determines the patient's signs and symptoms through the four examinations. Those signs and symptoms are then analyzed according to the logic of Chinese medical theory. Through this analysis, the practitioner can discriminate one pattern from another, eventually stating the patient's pattern discrimination in appropriate, standard professional terminology. Based on this pattern, the practitioner states the treatment methods necessary in principle to correct the disharmony implied by the name of the pattern, then consults information corresponding to the first principle, regardless of the disease diagnosis.
Example: Two patients may have a common cold. The first patient has a fever, slight sweating, a severe sore throat, a stuffy nose and a little dry cough. The patient's tongue is slightly red with white or slightly yellow fur, while their pulse is floating and rapid.
The second patient also has a fever with slight sweating, as well as a sore throat and cough. However, the second patient is also experiencing alternating fever and chills, is fatigued, and has no appetite. The patient's tongue is slightly red; the fur is yellow on one side and white on the other. In addition, their pulse is bowstring and rapid.
In the first case, the pattern discrimination is a wind heat exterior pattern; in the second, it is a shao yang division condition. Therefore, the logical treatment principles (at least according to the logic of Chinese medicine) for treating the first case are to resolve the exterior and clear heat. For the second case, the treatment principles are to harmonize the constructive and defensive. This means that one must (and will) find a remedy for the first patient using acrid, cool formulas that resolve the exterior and clear heat. The remedy for the second patient must (and will) be found using formulas that harmonize the constructive and defensive.
Treatment based primarily on pattern discrimination is the prescriptive methodology of professional Chinese medicine. It is a wonderfully wise prescriptive methodology, because it takes into account the figure and the ground; the forest and the trees; and the disease and the person who has it.
Click here for previous articles by Bob Flaws, LAc, FNAAOM (USA), FRCHM (UK).